MCN MOD 5.3

• Physiologic retraction ring


  Changes in uterine musculature to promote the expulsion of the fetus
• Upper uterine segment


  • Active and thick segment, provides stronger contractions
• Lower uterine segment

  • Passive, thin, and softer
• Pathologic retraction ring

  Also known as Bandl's ring, originates from physiologic retraction ring, occurs at the junction of the upper and lower uterine segment
• Pathologic retraction ring

  • Appears during the 2nd stage of labor as a horizontal indentation across the abdomen (can be palpated)
  • Fetus is gripped by a retraction ring and cannot advance beyond that point
  • Undelivered placenta will also be held at that point
• Pathologic retraction ring is a warning sign that severe dysfunctional labor is occurring
• Causes of pathologic retraction ring

  • Excessive retraction of the upper segment of the uterus
  • Prolonged second stage of labor
  • Early labor: uncoordinated contractions
  • Pelvic division of labor: obstetric manipulation or by the administration of oxytocin
• Signs and symptoms of pathologic retraction ring

  • Upper uterine segment is thicker while lower uterine segment is thinner, forming a gate that prevents fetal and placental expulsion due to excessive retraction
  • Horizontal indentation across the abdomen instead of a globular one
• Complications of pathologic retraction ring

  • Fetal death (if situation is not relieved)
  • Uterine rupture and neurological damage to the fetus
  • Retained placenta, leading to massive hemorrhage
• Management of pathologic retraction ring

  1. Assess full bladder

  2. IV morphine sulfate or inhalation of amyl nitrite: depressant, reduction of signals from the brain going to the maternal body, may relieve a retraction ring

  3. Tocolytics: halt contractions, temporarily stop labor to have effective and synchronous contractions

  4. Cesarean section to ensure safe birth of the fetus

  5. Manual removal of the placenta under general anesthesia if the retraction ring does not allow the placenta to be delivered
• Premature labor


  Labor that occurs before the end of week 37 of gestation (between 20–37 weeks of gestation)
• Premature labor occurs in approximately 9–11% of all pregnancies and is responsible for almost two-thirds of all infant deaths in the neonatal period
• Signs of premature labor

  • Strong, regular uterine contractions
  • Early cervical dilation and effacement
  • Birth of a premature baby
• Common causes of premature labor

  • Unknown causes (accounts for almost half of the cases)
  • History of premature labor with an early delivery
  • One or more spontaneous second-trimester abortions
  • Low socioeconomic factors
  • Low pre-pregnancy weight
  • Pregnancy age of less than 18 years or more than 40
  • Teenage primigravida
  • People of color ("nonwhite", e.g., African-American)
  • Maternal smoking and use of cocaine
  • Stressful living conditions
  • Intimate partner violence and trauma
  • Job that requires physical labor
  • Overdistention of uterus
  • Uterine abnormalities
  • Previous uterine surgery
  • Short cervix
  • Sexually transmitted diseases
  • Asymptomatic bacterial infections
  • Untreated acute pyelonephritis
  • Bacterial vaginosis
  • Infection of amniotic fluid (chorioamnionitis)
  • Periodontal diseases
  • Premature rupture of membranes
  • Congenital malformation of the fetus and placenta
  • Abnormal placentation
  • Fetal death
  • Retained IUD
  • Complication of pregnancy that requires immediate delivery
• Risk factors for premature labor

  • Dehydration
  • Chorioamnionitis/UTI
  • Adolescents
  • Women with inadequate or lacking prenatal care
  • Women who continuously work at strenuous jobs during pregnancy
  • Women who perform shift work leading to extreme fatigue
• Signs and symptoms of premature labor

  • Persistent, dull, low backache
  • Vaginal spotting
  • Feeling of pelvic pressure or abdominal tightening (10 mins)
  • Menstrual-like cramping
  • Increased vaginal discharge
  • Uterine contractions (true labor = perform D&E)
  • Watery fluid (ruptured BOW)
  • Decreased fetal movements
  • Women having 4 contractions every 20 minutes is in labor
  • Cervical effacement of 80% or dilatation of more than 1 cm
• Fetal fibronectin


  Protein produced by trophoblast cells, its presence in vaginal mucus predicts that preterm labor is ready to occur, absence means labor will not occur for at least 14 days
• Management of premature labor

  1. Comfort measures: Bed rest to relieve pressure of fetus on the cervix, IVF to keep women hydrated

  2. Monitoring: Attach mother to external fetal and uterine monitor, obtain vaginal and cervical culture and clean catch urine to rule out infection

  3. Pharmacological interventions: Tocolytic agent to halt labor, Ritodrine hydrochloride or terbutaline, Magnesium Sulfate, Prophylactic antibiotics, Corticosteroids to hasten fetal lung maturity
• Precipitate labor and birth


  Labor that is completed <3 hours
• Common causes of precipitate labor

  • Grand multiparity
  • Post-amniotomy
  • Smooth birth canal
  • Baby's size is smaller than the average size
  • Use of prostaglandin to induce labor
  • Conception using fertility treatments
• Risk factors for precipitate labor

  • Grand multiparity
  • Induced labor through amniotomy or oxytocin
  • Previous history of precipitate labor
• Signs and symptoms of precipitate labor

  • Precipitate dilatation during the active phase: 5cm/hr (1 cm every 12 minutes) in nullipara, 10cm/hr (1 cm every 6 minutes) in a multipara
  • Complains of sudden, intense urge to push
  • Sudden increase in bloody show
  • Sudden bulging of perineum
  • Sudden crowning of the presenting part
• Complications of precipitate labor

  • Premature separation of the placenta (abruptio placenta)
  • Subdural hemorrhage
  • Perineal lacerations
  • Inhalation of amniotic fluid
• Management of precipitate labor

  Anticipatory guidance (prevention): Prenatal care, explain what happens during the precipitous labor, instruct the significant other about what to expect, caution a multiparous patient by week 28 of pregnancy
• Precipitate dilatation during the active phase

  1. 5cm/hr (1 cm every 12 minutes) in nullipara

  2. 10cm/hr (1 cm every 6 minutes) in a multipara
• These signs and symptoms occur normally during labor. The only difference is that they occur suddenly and abruptly without warning.
• Management of precipitate labor

  1. Anticipatory guidance (prevention)

  2. Discontinuation of oxytocin

  3. Tocolytic agent

  4. Don't leave patient alone

  5. Prepare for delivery

  6. Elective induction of labor
• Uterine prolapse


  • Occurs when pelvic floor muscles and ligaments stretch and weaken, providing inadequate support for the uterus
• Vaginal pessary


  Plastic uterine support for mild cases of prolapse, an object inserted in the vagina to hold the uterus in place
• Uterine rupture


  • Rupture of the uterus during labor, uterus undergoes more strain than it is capable of sustaining
• Uterine rupture occurs in 1 in 1,500 births and causes 5% of all maternal deaths
• Problems with the psyche

  • Inability to bear down properly
  • Fear or anxiety about labor process
• HYSTERECTOMY 


  Removal of the uterus
• What is the preventive measure for uterine prolapse?

  Kegel's exercise
• Types of Uterine Rupture

  Impending Uterine Rupture

  Incomplete Uterine Rupture

  Complete Uterine Rupture
• IMPENDING RUPTURE 


  Sudden, severe pain during strong labor contractions reported as “tearing sensation”
• INCOMPLETE RUPTURE: less evident signs of rupture 


  ● Perimetrium still intact

  ● Localized tenderness with persistent aching over the area of the lower uterine segment

  ● Changes in maternal vital signs and FHT d/t decreased blood flow (hypovolemic shock from tearing of blood vessels)

  ● no contractions

  ● Incision is present but the baby is still inside
• COMPLETE RUPTURE 


  ● Runs through the endometrium, myometrium, and perimetrium

  ● Sudden stop in uterine contraction

  ● TWO DISTINCT SWELLINGS: retracted uterus and extrauterine fetus

  ● Hemorrhage (torn uterine arteries)

  ● WOF signs of shock (rapid, weak pulse, falling BP, cold and clammy skin, dilatation of nostrils = air hunger)

  ● FHT fades and then becomes absent
• What is the management for uterine rupture?

  Immediate CS delivery
• They may become almost immediately angry the rupture occurred, especially if the fetus died and the birthing parent will no longer be able to have children